NEW PALTZ, NY - A state inspection at Woodland Pond at New Paltz revealed concerns about staffing levels during overnight hours, with multiple residents reporting extended wait times for assistance with basic care needs and call bell responses that sometimes exceeded 30 minutes.
Overnight Staffing Raises Concerns
The facility's nighttime staffing configuration emerged as a primary issue during an April 2025 inspection. Multiple residents reported that two certified nurse aides were responsible for providing care to approximately 40 residents during overnight shifts, a ratio they described as inadequate for meeting basic care needs.
According to inspection findings, residents consistently reported being unable to receive timely assistance with transfers to bed and incontinence care during evening and overnight hours. Several residents stated they routinely waited until the day shift arrived at 7 AM to receive help with these fundamental activities of daily living, despite needing assistance during the preceding 12-hour period.
The staffing pattern showed a notable disparity between shifts. While day shifts operated with three certified nurse aides, the overnight period frequently had only two staff members covering the same number of residents. One certified nursing assistant confirmed that although nurses provided some assistance with call bells and resident care during short-staffed periods, the resident assignment remained split between two aides rather than being redistributed to create a more manageable three-way division of responsibilities.
Extended Wait Times Documented
The inspection revealed specific instances where response times significantly exceeded reasonable standards. The facility's Director of Nursing acknowledged that one resident experienced a 66-minute wait for incontinence care, stating that wait times exceeding 20-25 minutes were considered unreasonable according to the facility's own audit criteria.
Incontinence care represents a critical aspect of nursing home operations, as prolonged exposure to moisture can lead to skin breakdown, pressure injuries, and urinary tract infections. Clinical guidelines recommend prompt toileting assistance both for resident dignity and to prevent medical complications. Extended delays in providing this care can result in discomfort, skin irritation, and an increased risk of pressure ulcers, which are painful and costly to treat.
A family member reported that when staff responded to call bells, they frequently indicated needing a second person to provide assistance but then failed to return for 20-30 minutes. This pattern suggests coordination challenges between staff members and potential workflow inefficiencies that affected multiple residents throughout their stays.
Impact on Resident Care Needs
The staffing concerns took on additional significance given the clinical complexity of the resident population. Staff members noted that many residents required mechanical lifts for transfers, a process that requires two trained staff members working together. When only two aides cover an entire unit of 40 residents—many needing two-person assistance—the mathematical reality creates situations where some residents must wait while staff attend to others.
The inspection documented an instance where residents were instructed to urinate in their briefs because they had not had a bowel movement. This instruction raises questions about care practices and the assessment of individual resident needs, as clinical protocols typically evaluate continence care based on each person's specific toileting patterns and requirements rather than applying blanket policies.
Residents requiring two-person transfers for safety cannot be moved by a single aide, meaning that during periods when both overnight staff members are occupied, additional requests must queue until staff become available. This structural limitation becomes particularly problematic during peak times, such as evening hours when residents prepare for bed.
Additional Issues Identified
The inspection also documented concerns raised during a resident council meeting about the timing of bedtime assistance. Some residents reported that day shift staff were utilized to help them get into bed because waiting for night shift assistance, which began at 7 PM, would result in excessively long delays.
The facility's Director of Nursing maintained that current staffing numbers were adequate to provide necessary care. However, this assessment appeared to conflict with both resident reports and the facility's own documentation of wait times that exceeded internal standards.
The state inspection identified these concerns as part of a complaint investigation conducted on April 24, 2025. The findings indicate that while the facility had established internal benchmarks for reasonable response times, actual performance during overnight hours frequently fell short of these standards when staffing levels dropped to two certified nurse aides per unit.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodland Pond At New Paltz from 2025-04-24 including all violations, facility responses, and corrective action plans.
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